Exploring Health Reform and Criminal Justice:
Rethinking the Connection Between Jails and
Community Health Meeting

Wednesday, November 17, 2010
Washington, DC

Thank you, Nancy, and good morning to all of you. It's terrific to be here, and I'd like to thank the Robert Wood Johnson Foundation and the Langeloth Foundation for underwriting this important meeting. My tremendous thanks, also, to Community Oriented Correctional Health Services for organizing and hosting today's event. I look at the participant list and see that you've brought together an incredibly impressive group of people, so I know the discussions here are going to be thoughtful and productive.

I'm so pleased to be part of this conversation about the intersection of health reform and public safety. The provisions of the Patient Protection and Affordable Care Act provide an unprecedented opportunity, as you're saying here, to rethink correctional health.

I've long been concerned about the impact of poor inmate health, not only on the inmates themselves and the institutions to which they're confined, but on public health generally — and on public safety. As I've said before, correctional health care is a public safety issue, and we can't forget that.

Before I came back to OJP, I had the privilege of serving on the Vera Institute's Commission on Safety and Abuse in America's Prisons. In the testimony we heard from corrections officials, former inmates, and other experts, some troubling accounts had to do with health care. . . or lack of it.

And those anecdotal accounts are backed by statistics.

A 2002 study by the National Commission on Correctional Health Care found that every year, more than 1.5 million people are released from jail and prison carrying a life-threatening infectious disease. An earlier study found that those who pass through America's correctional institutions account for nearly a quarter of the general population living with HIV or AIDS, almost a third of those with hepatitis C, and almost 40 percent of people with tuberculosis.

On top of these physical ailments, a disproportionate percentage of people with mental illness cycle in and out of jails and prisons. A study from our Bureau of Justice Statistics based on surveys of prisoners and jail inmates found that 16 percent have a history of mental illness. That means that well over one million bookings of people with serious mental illness may occur every year. And what's so frightening is that only 18 percent of these inmates report receiving any treatment after admission.

For years now, it's been observed that detention facilities are the new asylums. Unfortunately, these new asylums are ill equipped for such a role.

And then there's the problem of substance abuse, as I don't need to tell those of you in this room. Data from our Bureau of Justice Statistics tell us that more than half of all state inmates were abusing or dependent on drugs in the year before their admission to prison. By way of comparison, the last published National Survey on Drug Abuse and Health from SAMHSA found that nine percent of the general population was classified with substance dependence or abuse in the past year. And we know that few who need substance abuse treatment actually receive it.

These statistics explode the notion that prisons and jails are sealed institutions. We know better. Almost everyone who enters a prison or jail will eventually return to his or her community — many in a matter of days and weeks, not years. And in a vast majority of cases, the time spent behind bars is not a period of physical or psychological rehabilitation, but rather an invitation for an illness to entrench its effects.

In terms of scale, some 735,000 people come out of America's prisons every year, and 9 million cycle through our jails. Given these large numbers — and the high percentage of inmates and detainees with medical, psychological, and substance abuse problems — we're dealing with a potentially serious public health — and public safety — issue.

To my mind, dealing with this problem requires looking at the issue of correctional health care the way we look at all aspects of reentry — namely, that reentry back into the community begins the moment an offender enters the system. This means early screening and assessment to detect and identify core health issues, appropriate institutional treatment, and continuity of care in the community. Sounds easy, right?

And if the challenges I outlined earlier weren't enough, let's not forget — as surely you haven't — that these are deep-rooted problems that weren't created by the corrections system. As we put it in our report for the Vera prison commission, "many of the biggest so-called prison problems are created outside the gates of any correctional facility."

Dr. Veysey points out in her paper that these offenders are disproportionately poor and have high rates of health problems, psychiatric disorders, and addictions coming into the system. I like the way she put it — if I can just quote from you, Dr. Veysey: "Upon booking. . . arrestees are often at their sickest."

Prisons and jails inherit the medical, psychiatric, and addiction problems of those over whom they have custody. And despite the resource challenges and the large numbers of inmates and detainees needing help, some of those institutions have done commendable and even stellar work to reverse those problems. It sounds remarkable in the face of the obstacles, but in some cases, people actually return to their communities in better shape than when they left them.

But in these cases, the health gains are often squandered without continuity of care or adherence to the treatment regimens. It's essential that we figure out how to scale up the model being implemented in Hampden County and the COCHS sites.

Now, with the enactment of the Affordable Care Act, I believe we have an incredible opportunity to build on those pockets of progress. As you well know, access to health care services in prisons and jails has always been a complicated issue. Those who are incarcerated have a constitutional right to health care, yet federal benefits are either suspended or terminated once a person goes behind bars. This leaves the burden on the institution to provide care, and the resources for meeting this responsibility — and the commitment to do so — vary widely among jails and prisons.

Then there are pre-trial detainees — those who haven't been found guilty of a crime and aren't legally precluded from receiving benefits, yet who still find themselves effectively excluded from care. These detainees make up the majority of the jail population. Many of them come in to the system, and no sooner have they been processed and admitted than they're back out again, except that now they don't even have the means to access basic care.

So, of course, what happens is that they rely on emergency rooms and other urgent care for treatment. And we all know that this is extremely expensive — and the cost of it falls squarely on the taxpayer. Not to mention, it's not an effective approach in the long run.

The new Health Care law presents us with an opportunity to address what I think is the biggest challenge in correctional health care — and that is continuity of care. By 2014, the obstacles to coverage may be eliminated for detainees, and so community-based providers will have an incentive to work closely with jails and prisons to serve the needs of their populations.

We've already seen good examples of this kind of collaboration — most notably, of course, the Hampden County model, which matches inmates with treatment providers based on the inmate's home zip code so that treatment can continue uninterrupted after release. This kind of connection is so important because even where good institutional treatment is provided, it often falls off at release. Fewer than 20 percent of annual jail admissions stay longer than 1 month, so continued community care is paramount.

Now, I think, is the time to be building these partnerships. As the Hampden County experience demonstrates, there's nothing to prevent us from developing these relationships now. In fact, there are more than 1,200 Federally Qualified Health Centers serving some 6,600 communities that are designed to meet the medical needs of underserved populations — and many of these centers are already working with correctional institutions. To other providers, we can make a strong case for working together based on the potential public safety impact, on inmate health, and on cost.

Partnerships are key to meeting correctional health care challenges, but I don't want to sell partnership as a panacea. Resources across the board remain scarce, and even a strategic pooling of resources can't be expected to solve all our problems. I think we also need to set some priorities and not expect that we'll be able to achieve community standards of care for every inmate or detainee in every case.

This, I think, begins with a quick screen followed by thorough assessments of risk and need. Assessment is one of the pillars of any public health approach, but it's even more critical in the corrections arena, particularly given the often short jail stays of many who come into the system. In many cases, assessment may be the only interface with correctional health care. In these cases, assessment serves to identify who needs treatment services on the outside, and it identifies what, specifically, needs attention in the treatment plan.

Risk assessment — even beyond medical and psychiatric issues — is the bedrock of effective reentry — and I feel compelled to point out that, from a public safety standpoint, correctional health care is very much a reentry issue. I think we need to let risk and need help us sort out who to focus our resources on. This means universally screening inmates and prioritizing who gets services.

Also, there are basic administrative obstacles to continuing care that must be addressed. Reinstating Medicaid benefits, for example, can take months, and so those who were so ill at admission return to the community with no coverage — at least for the short-term.

But there's nothing preventing correctional agencies from working with Social Security offices to ensure that benefits are reinstated when an inmate is released. In fact, SSA has pre-release agreements with about 700 state and local prisons and jails. This could — and should — be part of discharge planning so that returning offenders can begin to receive services immediately upon release.

I know these are complex issues, and resolving them will require a lot of strategic planning and even changing some attitudes, which I know is sometimes the biggest challenge of all! I believe we at the federal level have an important responsibility to help lead this shift.

One way we're trying to do this is through an interagency reentry working group. My agency is leading this staff-level effort, and the Attorney General will be creating a parallel Cabinet-level group. The issues you're discussing here and that are set forth in the commissioned papers will help inform our discussions.

Amy Solomon and Marlene Beckman of my staff (both of whom are here today) are heading up the staff-level group — and I know there are several others here from partner agencies across the government. Amy and Marlene have already met with Nancy and Steve to talk through some of these issues.

When I spoke to the American Correctional Association's Health Care Professional Interest Section in January, I pledged that this Administration — and this Department of Justice — are committed to improving the health care delivery system in our nation's correctional institutions. This is evidence of that commitment.

We're moving forward in other ways, as well. Last month, the Attorney General announced $100 million in awards under the Second Chance Act to support 178 reentry grants nationwide. This is on top of 70 reentry grants we awarded last year. Some of these focus on health care in our nation's jails. A good example is the Allegheny County Jail Collaborative in Pennsylvania.

This is a partnership between the jail, the county health department, and the county's Department of Human Services. Inmates are screened at intake and referred to a variety of programs, including mental health and substance abuse treatment. The partners meet monthly to plan all in-jail, transitional, and post-release services so that treatment continues after release. An evaluation from the University of Pittsburgh found that recidivism rates were half those of non-participants, and that the program saved the county more than $5.3 million annually.

The Allegheny program — and others like it — are proof positive that we have the ability to improve health care delivery in our nation's jails and prisons — and to enhance community safety into the bargain.

I'm excited about this moment. We're now seeing a convergence of opportunity and innovative thinking in the correctional health care arena. We know that the challenges, while not insignificant, are within our power to meet. And in meeting these challenges, we know that we can make a huge, positive difference in public health and safety.

As we said in the report for the prison commission, "[p]rotecting public health and public safety, reducing human suffering, and limiting the financial cost of untreated illness depends on adequately funded, good quality correctional health care." There's no question that the work each of you is doing is vital to a healthy — and safe — society. If we can add the community element — and the Affordable Care Act may give us a chance to do that — we have a monumental opportunity to change the landscape.

Keep up your good work, keep your commitment strong, and let's use this moment to make a correctional health network we can all be proud of.